Free K-WC 124 (Rev. 10-04).indd - Kansas

DIVISION OF WORKERS COMPENSATION KS DEPARTMENT OF LABOR
800 SW JACKSON ST STE 600 TOPEKA KS 66612-1227 Phone: 785-296-3441 ­ Fax: 785-296-0839 Web Site: www.dol.ks.gov

Cancellation of Election of Employer to Provide Workers Compensation Coverage for Volunteer Workers
NOTICE: To be processed, ALL entries on this form must be completed. All entries, except signatures, must be neatly printed in black ink. NOTE: This Cancellation of Election is effective upon receipt by the Kansas Division of Workers Compensation.

To the Kansas Division of Workers Compensation, you are hereby notified that: Employer Name: ___________________________________________________________________ Employer Address:_____________________________________________________________________ _____________________________________________________________________ hereby cancels its previous election to provide workers compensation coverage for volunteers within the provisions of the Kansas Workers Compensation Act.

Valid Signature of Employer or Authorized Representative

Title of Signing Individual

Date of Signature

K-WC 124 (Rev. 10-04)